Blood pressure targets after return of circulation following cardiac arrest in infants and children: a systematic review and meta-analysis

Gabrielle Nuthall; Andrea Christoff; Laurie J Morrison; Jason Acworth; James M Gray; Joseph Rossano; Barnaby R Scholefield; International Liaison Committee on Resuscitation ILCOR Pediatric Life Support Task Force

doi:10.1016/j.resuscitation.2025.110825

Blood pressure targets after return of circulation following cardiac arrest in infants and children: a systematic review and meta-analysis

Resuscitation. 2025 Sep 16:216:110825. doi: 10.1016/j.resuscitation.2025.110825. Online ahead of print.

Authors

Gabrielle Nuthall¹, Andrea Christoff², Laurie J Morrison³, Jason Acworth⁴, James M Gray⁵, Joseph Rossano⁶, Barnaby R Scholefield⁷; International Liaison Committee on Resuscitation ILCOR Pediatric Life Support Task Force

Collaborators

International Liaison Committee on Resuscitation ILCOR Pediatric Life Support Task Force:
Kee Chong Ng, Tia T Raymond, Raffo Escalante-Kanashiro, Arun Bunsal, Alexis Topjian, Stephan Katzenschlager Hiroshi Kurosawa, Jana Djakow, Anne-Marie Guerguerian, Stephen M Schexnayder, Gene Yong-Kwang Ong, Jesus Lopez-Herce, Ester Ambunda, Allan DeCaen, Dianne L Atkins

Affiliations

¹ Department of Critical Care, Starship Children's Hospital, Auckland, New Zealand. Electronic address: GabrielleN@adhb.govt.nz.
² Department of Critical Care, The Children's Hospital at Westmead, Sydney, Australia.
³ Department of Emergency Services, Sunnybrook Health Sciences Center, Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Canada.
⁴ Department of Emergency Medicine, Queensland Children's Hospital, Brisbane, Australia.
⁵ Department of Emergency Medicine, Cincinnatti Children's Hospital, Cincinnatti, the United States of America.
⁶ Department of Pediatrics, Division of Cardiology, University of Pennsylvania, PA, the United States of America.
⁷ Department of Critical Care, Hospital for Sick Children and University of Toronto, Toronto, Canada.

PMID: 40967393
DOI: 10.1016/j.resuscitation.2025.110825

Abstract

Aim: To systematically review the literature examining optimal blood pressure targets following in-hospital or out-of-hospital cardiac arrest in infants and children. (PROSPERO ID CRD42023483865).

Methods: We searched Medline, EMBASE, and Cochrane Controlled Register of Trials (CENTRAL) for randomised controlled trials and non-randomised studies for all years up to March 19, 2025. Risk of bias and certainty of evidence was assessed using Newcastle-Ottawa and GRADE. Critically important outcomes survival to hospital discharge and survival with favourable neurological outcome.

Results: We identified 11 observational studies, including 2855 cardiac arrest events in infants and child. No randomised clinical trials were found. Patients exposed to a systolic blood pressure (SBP) greater than 5th percentile for age within six hours of return of circulation, compared to less than 5th percentile had a higher risk of survival to hospital discharge (RR 1.41; 95 % CI [1.2-1.6]; P = 0.01) and better survival with favourable neurological outcome at hospital discharge (RR1.25; 95 % CI [1.11-1.64]; P = 0.01). Exposure to a SBP greater than 10th centile for age was also associated with increased survival at hospital discharge and survival with favourable neurological outcome at hospital discharge (RR 1.21; 95 % CI [1.00-1.33}; P < 0.01 and RR 1.22; 95 % CI [1.10-1.35}; P < 0.01 and RR respectively). Mean Blood Pressure targets (>10th percentile) and diastolic blood pressure targets (>50th percentile) were also reported and associated with improved critical outcomes. However, variation in time points, blood pressure definitions and outcome assessment limited pooled analysis. Risk of bias was low, and the certainty of evidence was very low.

Conclusion: Early hypotension after return of circulation post cardiac arrest is associated with worse outcomes in infants and children after cardiac arrest. Patients exposed to systolic or mean arterial blood pressure targets greater than fifth and tenth percentile for age have improved risk of survival to hospital discharge and survival with favourable neurologic outcomes at hospital discharge.

Keywords: Blood pressure; Cardiopulmonary resuscitation; Child; Hypotension; Infant; Post cardiac arrest; Return of circulation.